Review Durable Medical Equipment Providers' Medicaid Claims for Residents of Assisted Living Programs

EXECUTIVE SUMMARY:

Our objective was to determine whether durable medical equipment (DME) providers improperly received Medicaid reimbursement for medical supplies and equipment not requiring prior approval that were already included in the per diem rates paid to assisted living programs (ALPs). New York prohibits Medicaid payments to DME providers for items furnished by a facility or organization when the cost of those items is already included in the per diem rate. The DME providers improperly received Medicaid reimbursement for medical supplies and equipment not requiring prior approval that were furnished to ALP residents. As a result, $406,081 in Federal funds was improperly claimed under the Medicaid program. Our report recommended that the State: (1) refund $406,081 to the Federal Government, (2) establish eMedNY edits and controls necessary to deny DME provider claims for Medicaid reimbursement for medical supplies and equipment not requiring prior approval that were furnished to ALP residents, and (3) issue guidance to DME providers emphasizing that State regulations prohibit Medicaid payment for items included in the ALPs' per diem rates. The State generally concurred with all three recommendations.